Nicohwilliam

Case Study*

“Olivia Jacobs, a 22 year old graduate student in architecture, was referred for an urgent psychiatric consultation after she told her roommate that she was suicidal. Ms. Jacobs had a history of mood symptoms that had been under good control with lithium and sertraline, but her depressive symptoms had returned soon after she had arrived in a new city for school, 3 months earlier. She had become preoccupied with ways in which she might kill herself without inconveniencing others. Her dominant suicidal thoughts involved shooting herself in the head while leaning out the window, so as not to cause a mess in the dorm. Although she did not have access to a gun, she spent time searching the Web for places where she might purchase one.

Ms. Jacobs’s psychiatric history began at age 15, when the began to regularly drink alcohol and smoke marijuana, usually when out a t dance clubs with friends. Both of these substances calmed her, and she denied that either had become problematic. She had used neither alcohol nor marijuana since starting graduate school.

Around age 17, she began experiencing brief, intensive depressive episodes, marked by tearfulness, feelings of guilt, anhedonia, hopelessness, low energy, and poor concentration. She would sleep more than 12 hours a day and neglect responsibilities at school and home.

These depressive episodes would generally shift after a few weeks into periods of increased energy, pressured speech, and unusual creativity. She would stay up most of the night working on projects and building architectural models. These revved-up episodes lasted about 5 days and were punctuated by feelings that her friends had turned against herald that there were not really friends at all. Worried especially about the paranoia, her family brought her to a psychiatrist, who diagnosed her as having bipolar II disorder and prescribed lithium and sertraline. Although Ms. Jacobs’s moods did not completely stabilize on this regimen, she did well enough at a local university to be accepted into a prestigious program far from home. At that point the depression returned, and she became intensely suicidal for the first time.

Upon evaluation, the patient was visibly depressed and tearful, and had psychomotor slowing. She said it was very difficult to get out of bed and she was not attending class most days. She reported hopelessness, poor concentration, and guilt about spending family money for school when she was not able to perform. She stated that she thought about suicide most of the time and that she had found nothing to distract her. She denied recent drinking or smoking marijuana, stating she did to feel like “partying.” She acknowledged profound feelings of emptiness, and indicated that she had occasionally cut her arms superficially to “see what it would feel like.” She stated that she knew that cutting herself this way would not kill her. She reported depersonalization and occasional panic attacks. She denied having mood instability, derealization, problems with impulsivity, concerns about her identity, and fears of abandonment.”

*Oquendo, M.A. In Barnhill, J.W. (Ed.) 2014.